Optimizing The Revenue Cycle 4 of 12: Check In/ Check Out

Posted by Crystal L. Miner, MBA-HSA, FACMPE on Jan 3, 2019 7:46:00 AM
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When checking in at a hotel, what makes it so painless and easy? The fact you know when to show up and what is expected of you, probably. You told the hotel you would be there on the 12th, and they have a regular check-in time of after 3 pm which works for your schedule. Upon arrival, you tell them your name and give them your photo ID and credit card. You know this is so that they can verify your identity and get paid for the room you are about to use. They may ask to confirm how many nights you are staying, just to be sure, but that is all. Then you sign the paperwork saying you won’t destroy their property and that you authorize the hotel to charge your card, they hand over the room key and off you go! 

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Obviously, checking in at a medical clinic will rarely be as smooth as checking in at a hotel, but we could get close. In addition, our collections at the front desk should be just as good. The key is to set expectations for our customers. People coming to see their doctor expect to pay everywhere else they go – why not at the doctor’s office? Times have changed from when insurance companies “covered everything.” The current trend is now for them to cover “after deductible” instead. If we can educate and support patients with this new expectation, we will see smoother check-ins and an optimized revenue cycle.


The other reality is that check-in and check-out are the last opportunities the clinic has to assure all information for a patient is current before billing. If any item is incorrect, the claim errors and denials will cause costly delays in payment. If clinics are unable to have registration (collection and verification of demographics and insurance information) and insurance eligibility verification done pre-visit, then these must be done at check-in. Not accomplishing these tasks pre-visit may be due to their lack of practicality (emergency care) or the visit type (same day visits as encouraged by PCMH). Even patient population (age or location) may limit a clinic’s ability to gather information pre-visit. However, this only increases the time of service workload for the front desk team. It does not reduce the extreme importance of these tasks, the need for a high level of attention to detail, or the training need of the check-in/check-out team to assure they are aware of their place and importance in the revenue cycle.


When I questioned an owner of a billing and coding company about what tips and tricks she often gives administrators, she stated that “it really begins at registration. If the insurance and demographics are not accurate, the whole charge entry is in jeopardy.” She went on to say, “the insurance being entered incorrectly can cause the coding to be inaccurate. We really do all work as one and any error along the way has an effect.” It is vitally important that a clinic’s billing team and front desk team are cohesive and see each other as partners, not “Us” vs “Them.”


As administrators look for ways to help ease the load at the front desk, there are a few options. The first is the concept of a check-in kiosk. Many airlines have these available for passengers to check-in at the airport for their flights. Some restaurants, like Panera, are using similar kiosks for customers to order and pay for their food. There are only a few vendors currently supplying kiosks, but a number of EHRs are creating a version for their users. This add-on software is then loaded onto a tablet that is given to patients at check-in. Any automated check-in/registration process should ultimately interface with a clinic’s practice management system. This allows patients to enter their information directly into the system and eliminates potential errors from staff members. Photo IDs and insurance cards should be scanned into the system for quick recall should an error be found later.


Another way to break up the workload is to have a dedicated position for insurance verification and billing conversations with patients. These positions used to be called counselors but are now titled Patient Account Representative or Financial Advocate. These new titles show patients that clinics are partnering with them to understand the complex world of insurance and medical billing. These positions can discuss financial agreements, insurance waiver forms (ABN), surgical estimates, and payment plans. This allows check-in/check-out staff to focus on the details of registration, scheduling and cashiering.


So how does an administrator know if they have been able to optimize the check-in/check-out process? The Physician Billing Process: Navigating Potholes on the Road to Getting Paid has an audit tool that can help. There are also a number of data points included in this MGMA bestseller, on its 3rd version, that can assist. One example is a staffing metrics that state that a check-in person with registration verification and cashiering should be able to check-in 75-100 patients a day while a check-out person performing scheduling and cashiering should process 70-90 patients. The book also has scripts to help your front desk team ask for payment at time of service.


Another step in verifying the optimization of the check-in/check-out process is to reconcile front desk collections. Comparing what should have been collected versus what has been collected daily is extremely important as the burden of medical costs has shifted to patients. Once a patient has left the visit, the chance of payment drops as much as 60% by some estimates. Here are the questions that a reconciliation report should answer:

  1. Patient name/account
  2. Balance on account (what patient owes)
  3. Amount charged for visit
  4. Copay according to insurance eligibility check/Amount patient due (co-insurance, deductible, etc.)
  5. Amount collected
  6. Any notes from staff on why the Amount Due is different from Amount Collected (examples: Patient left before checking out; Patient signed payment plan)


One way to assist with collections at the front desk, clinics can implement a policy of having a credit card on file. This has found popularity with many clinics as patient responsibilities have increased. Security compliance (HIPAA and PCI) should be considered when proceeding with these policies. However, with the numerous programs available to clinics to store and charge credit cards, meeting these guidelines and passing required security tests are relatively easy (do NOT store credit card data on your network). Thus, like a hotel, the clinic has the ability to be paid once the amount of the visit is known. The patient signs at check-in authorizing the clinic to charge the card for any amounts due.


With all of these steps in place, clinics should be able to educate patients on the expectations of the check-in and check-out process of the clinic. However, clinics must also continue to work hard to support patients in their understanding of insurance coverage and assure that appropriate forms (waivers, referrals, prior authorizations, etc.) are completed. In addition, front desk staff is tasked with mandatory attention to detail in regards to demographics, insurance, scheduling and cashiering. Any assistance administrators can give their teams in automation or additional dedicated positions has the potential of enhancing the overall outcome of the clinic’s revenue cycle.


This is Part 4 of a 12 part blogging series on How to Optimize The Revenue Cycle For Your Practice. Be sure to subscribe for email alerts to never miss an article. If you missed anything, check it out here: 12 Part Series 

Topics: revenue cycle management, Medical Practice Improvement, check-in